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Peripheral nerve injuries:

Peripheral nerve injuries By : - Dr .Sanjeev

Structure of a nerve:

Structure of a nerve It has an outer covering which forms a sheath around the nerve, called the epineurium . Nerve fibers, which are axons, organize into bundles known as fascicles with each fascicle surrounded by the perineurium . Between individual nerve fibers is an inner layer of endoneurium .

Peripheral nerve injury:

Peripheral nerve injury Dermotome : is an area of skin supplied by a single spinal root Myotome : Represents a muscle unit supplied by a single spinal root

Seddon's classification:

Seddon's classification Neurapraxia -- temporary paralysis of a nerve caused by lack of blood flow or by pressure on the affected nerve with no loss of structural continuity. Axonotmesis – neural tube intact, but axons are disrupted . nerves are likely to recover. Neurotmesis – the neural tube is severed. Injuries are likely permanent without repair .

Cont ..:

Cont .. Causes at the elbow : Compression by the accessory muscles # lateral epicondyle of humerus Repeated occupational strains Recurrent subluxation of the nerve Compression by the osteophytes as in rheumatoid and osteoarthritis Causes in the forearm : # both bones forearm Incised wounds , gunshot wounds and penetrating injuries of the forearm

Claw hand deformity :

Claw hand deformity It is a deformity with hyperextension of the MCP joints and flexion of the IP joints of the fingers ( loss of flexon at MCP and extension at IP joints )

Clinical features :

Clinical features Loss of sensation along the ulnar nerve distribution and Wasting of the hypothenar muscles , intrinsic muscles of the hand leading to hollow intermetacarpal spaces on the dorsum of the hand

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Levels of the lesion :

Levels of the lesion High : above the level of elbow , entire nerve function is lost Low : Below the elbow at the junction of the middle and lower third of forearm : Spared : - function of FDP and FUC Lost : Motor : HTM ,Its , Lum ,PB Sensory : dorsal aspect of hand and one and half fingers

Clinical tests ::

Clinical tests : Froment's sign. When the patient attempts to pinch with the thumb and index finger, the long flexor of the thumb is used to substitute for the thumb adductor, resulting in flexion of the thumb at the interphalangeal joint. This characteristic appearance is present in this patient's left hand, caused by an ulnar nerve lesion at the elbow

Card test :

Card test Inability to hold a card or paper in between fingers due to loss of adduction by the palmar interossei Pen test Unable to touch the pen due to the loss of action of abductor pollicic brevis

Egawa test ( median nerve injury ):

Egawa test ( median nerve injury ) With palm flat on the table the patient is asked to move the middle finger sideways( test for the dorsal interossei of middle finger ) In total clawing median nerve is also injuried Pointing index or oschner`s clasp test : When both the hands are clapsed together , index and middle fingers , fail to flex due to the loss of action of long finger flexors of the index and middle fingers which are supplied by the median nerve .

Treatment of ulnar nerve injury:

Treatment of ulnar nerve injury Unless there is a lot of muscle wasting, (nonsurgical treatment ) Prevention Avoid frequent use of the arm with the elbow bent If you use a computer frequently, make sure that your chair is not too low. Do not rest the elbow on the armrest. Avoid putting pressure on the inside of the arm (do not drive with the arm resting on the open window ). Keep the elbow straight at night when you are sleeping (done by wrapping a towel around the straight elbow, wearing an elbow pad backwards, or using a special brace ) Loosely wrapping a towel around the arm with tape can help you to remember not to bend the elbow during the night

Nonsurgical Treatment:

Nonsurgical Treatment If symptoms have only just started, Anti – inflammatory drugs, ibuprofen,( to reduce swelling around the nerve ). Steroid (cortisone) injections around the ulnar nerve are not generally used because there is a risk of damage to the nerve. Exercises ( prevents arm and wrist from stiffness ). With your arm forward and the elbow straight, curl the wrist and fingers toward the body, then extend them away from you and then bend the elbow With the arm to the side, curl the wrist and fingers toward the shoulder and then turn the palm up and then stretch the neck to the other side.

Surgical Treatment:

Surgical Treatment If the nerve is very compressed; or if there is muscle wasting Surgery : Around the elbow and the wrist or both More commonly, the nerve is moved from its place behind the elbow to a new place in front of the elbow. This is called an anterior transposition of the ulnar nerve. The nerve can be moved : - under the skin and fat (subcutaneous transposition ), within the muscle ( intermuscular transposition ) or under the muscle ( submuscular transposition ).

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. For anterior transposition of the ulnar nerve, an incision along the inside of the elbow is used. Nerve moved from behind the elbow to in front of it and will make sure that it is not compressed by any other structures .

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. Entrapment of the ulnar nerve at Guyon's canal. If ulnar nerve is compressed at the wrist, make an incision and free the nerve where it is compressed.

Ulnar paradox:

Ulnar paradox The higher the lesion of the median and ulnar nerve injury , the less prominent is the deformity and vice versa, because in higher lesions the long finger flexors are paralysed . The loss of finger flexion makes the deformity look less obvius

Cont ..:

Clinical features :

Clinical features Depend upon the site of the injury : - Lesions in or above the axilla : Paralysis and wasting of all the muscles innervated. Clinically, this is manifest as: weakness of forearm extension and flexion - triceps and brachioradialis wrist drop and finger drop - paralysis of the extensors of the wrist and digits weakness of the long thumb abductor and extensor muscles

Cont .. :

Cont .. Sensory loss on the dorsum of hand and forearm appropriate to the cutaneous distribution Lesions around the humerus spare brachioradialis and extensor carpi radialis longus. Posterior interosseous palsy (due to a dislocation or fracture of the elbow ). weakness of finger extension, and of thumb extension and abduction. little or no wrist drop, and usually, no sensory loss.

Sensation::

Sensation: The cutaneous branches of the radial nerve supply the dorsal aspect of the forearm from below the elbow down over the lateral part of the hand to include the thumb to the interphalangeal joint and the fingers to the distal interphalangeal joint.

Exams and Tests:

Exams and Tests An examination of the arm, hand, and wrist identify radial nerve dysfunction. Decreased ability to extend the arm at the elbow Decreased ability to rotate the arm outward (supination) Difficulty lifting the wrist or fingers (extensor muscle weakness) Muscle loss (atrophy) in the forearm Weakness of the wrist and finger Wrist or finger drop Tests for nerve dysfunction : EMG MRI of the head, neck, and shoulder Nerve biopsy Nerve conduction tests

Low lesions :

Low lesions Type 1 : Dorsiflexion and inversion is not possible Front of the leg is wasted Sensation over the dorsal web space is lost Type 2 : Cannot evert but can dorsiflex and invert the foot Wasting of the outer half of the leg Sensation lost over outer leg and foot Gait : - high stepping gait is characteristic .

Treatment :

Treatment Braces or splints. Physical therapy. Nerve stimulation : In some cases, a small, battery-operated electrical stimulator is strapped to the leg just below the knee. In other cases, the stimulator is implanted in the leg. Surgery. Tendon transfer ( for mobile foot drop ) Tendon – Achilles lengthening ( in fixed )

Treatment :

Treatment Different types of braces (also known as ankle-foot orthotics or AFOs) are used . Two standard motions that occur at the ankle joint – “dorsiflexion” and “plantarflexion”. Plantarflexion (toes point downward ). Dorsiflexion ( foot points upward ). Dropfoot ( partial or complete weakness of the muscles that dorsiflex the foot at the ankle joint ).

Dorsiflexion Assist AFO (dorsiflex the ankle) : :

Plantarflexion Stop AFO: :

Solid AFO: (stops plantarflexion and also stops or limits dorsiflexion).

Posterior Leaf Spring AFO :

Posterior Leaf Spring AFO Patients who have instability of the knee along with their dropfoot.

Brachical plexus injuries:

Brachical plexus injuries

Causes :

Causes Closed injury : Due to birth or Due to bike trauma Open injury : Due to penetrating or gunshot injuries Others ( less common ) Traction injuries Tumor removal Shoulder dislocations Surgical excision of cervical ribs Abnormal pressures due to faulty posture

Surgical measures :

Surgical measures Types of surgery Nerve graft : - the damaged part of the brachial plexus is removed and replaced with sections of nerves cut from other parts of body

Nerve transfers:

Nerve transfers Done in the most serious types of brachial plexus injuries, called avulsions, when the nerve root has been torn out of the spinal cord.

Muscle transfers:

Muscle transfers Needed if arm muscles have atrophied from lack of use.

ERBS PALSY :

ERBS PALSY

Erb's palsy:

Erb's palsy paralysis of the muscles in a baby's arm, caused by injury of the nerves in the shoulder at birth (during delivery). The baby lies with one arm and hand twisted backward and does not move the arm as much as the other. If the full range of motion of the arm is not kept through regular exercise, contractures will develop .

Clinical features :

Clinical features At the shoulder : Loss of shoulder abduction and external rotation ( due to paralysis of the deltoid , supra and infraspinatus and teres minor muscles ) At the elbow : Loss of flexion of the elbow joint ( due to paralysis of the biceps and brachialis ) At the forearm : Loss of supination of the forearm May be sensory loss on the outer aspects of the arm and forearm both in the front and back .